Insomnia

Insomnia refers to a prolonged inability to get adequate sleep. Not getting a good night’s sleep can result from waking up in the middle of the night and having trouble getting back to sleep. It also occurs when people have a hard time falling asleep in the first place. Insomnia can be a temporary, occasional, or chronic problem.

For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms of insomnia?

Sleep-onset insomnia refers to the inability to fall asleep initially. Sleep-maintenance insomnia refers to the inability to stay asleep, with one or more awakenings during the night.

Dietary changes that may be helpful for insomnia

Caffeine is a stimulant.1 The effects of caffeine can last up to 20 hours,2 so some people will have disturbed sleep patterns even when their last cup of coffee was in the morning. Besides regular coffee, black tea, green tea, cocoa, chocolate, some soft drinks, and many over-the-counter pharmaceuticals also contain caffeine.

Doctors will sometimes recommend eating a high-carbohydrate food before bedtime, such as a slice of bread or some crackers. Eating carbohydrates can significantly increase levels of a neurotransmitter (chemical messenger) called serotonin,3 which is known to reduce anxiety and promote sleep.

Food allergy may also contribute to insomnia. In a trial involving eight infants, chronic insomnia was traced to an allergy to cow’s milk. Avoidance of milk resulted in a normalization of sleep patterns.4

Lifestyle changes that may be helpful for insomnia

A steady sleeping and eating schedule combined with caffeine avoidance and counseling sessions using behavioral therapy has reduced insomnia for some people, as has listening to relaxation tapes.5

The effect of exercise on sleep has not been well studied. However, some healthcare practitioners recommend daily exercise as a way to reduce stress, which in turn can help with insomnia.

A naturopathic therapy for insomnia is take a 15- to 20-minute hot Epsom-salts bath before bedtime. One or two cups of Epsom salts (magnesium sulfate) in a hot bath are thought to act as a muscle relaxant.

Smokers are more likely to have insomnia than nonsmokers.6 As with many other health conditions, it is important for people with insomnia to quit smoking.

Nutritional supplements that may be helpful for insomnia

Melatonin is a natural hormone that regulates the human biological clock. The body produces less melatonin with advancing age, which may explain why elderly people often have difficulty sleeping7 and why melatonin supplements improve sleep in the elderly.8

Warning: Melatonin is a potent hormone and its long-term safety is not established. Melatonin should only be taken with medical supervision.

Middle-aged adults (average age, 54 years) with insomnia also have lower melatonin levels, compared with people of the same age without insomnia.9 However, there is not much research on the use of melatonin for sleep problems in middle-aged people.

Double-blind trials have shown that melatonin facilitates sleep in young adults without insomnia,10 but not in young people who suffer from insomnia.11 However, one trial found that children with sleep disturbances stemming from school phobia had improved sleep after taking 1 mg of melatonin per night for one week, then 5 mg per night for one week, then 10 mg per night for a third week.12

The results of one double-blind trial also indicate that a controlled release melatonin supplement providing 2 mg per day improves sleep quality in people with schizophrenia.13

Normally, the body makes melatonin for several hours per night—an effect best duplicated with controlled-release supplements. Trials using timed-release melatonin for insomnia have reported good results.14 Many doctors suggest taking 0.5 to 3 mg of melatonin one and a half to two hours before bedtime. However, because melatonin is a potent hormone, the long-term effects of which are unknown, it should be taken only with the supervision of a doctor.

The amino acid, L-tryptophan, has been used successfully for people with insomnia,15 presumably because it is converted to the chemical messenger, serotonin. According to one preliminary trial, L-tryptophan supplementation was 100% effective at promoting sleep in people who awaken between three to six times per night, but not effective at all for people who only awaken once or twice, nor in people who doze on and off throughout the night in a state blurred between sleep and wakefulness.16 However, L-tryptophan is no longer available over the counter in the United States. A related compound that occurs naturally in the body, 5-Hydroxytryptophan (5-HTP), is also converted into serotonin and might, therefore, be helpful for insomnia. In a double-blind trial of people without insomnia, supplementation with 5-HTP (200 mg at 9:15 p.m. and 400 mg at 11:15 p.m.) increased rapid-eye-movement (REM) sleep, presumably indicating improved sleep quality.17 In a preliminary trial of people with fibromyalgia, supplementing with 100 mg of 5-HTP three times a day improved sleep quality.18 However, additional research is needed to determine whether 5-HTP is safe and effective for people with insomnia.

Some people have difficulty sleeping because of a problem known as period limb movements during sleep (PLMS) or another condition called restless legs syndrome (RLS). In a preliminary trial, people with PLMS or RLS who suffered from insomnia had a significant improvement in sleep efficiency after supplementing with magnesium (about 300 mg each evening for four to six weeks).19

In two small preliminary trials, people with insomnia resulting from disorders of the sleep-wake rhythm improved after supplementing with vitamin B12 (1,500 to 3,000 mcg per day).20 21

Are there any side effects or interactions with insomnia?

Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful for insomnia

Herbal remedies have been used safely for centuries for insomnia. In modern herbal medicine, the leading herb for insomnia is valerian. Valerian root makes getting to sleep easier and increases deep sleep and dreaming. Valerian does not cause a morning “hangover,” a side effect common to prescription sleep drugs in some people.22 23 A double-blind trial found that valerian extract (600 mg 30 minutes before bedtime for 28 days) is comparable in efficacy to oxazepam (Serax®), a commonly prescribed drug for insomnia.24 In a separate double-blind trial, the same amount of valerian extract was found to improve subjective assessments of sleep quality and certain aspects of brain function during sleep as well.25 A concentrated (4–5:1) valerian root supplement in the amount of 300–600 mg can be taken 30 minutes before bedtime. Alternately, 2 to 3 grams of the dried root in a capsule or 5 ml tincture can be taken 30 minutes before bedtime.

A combination of valerian and lemon balm has been tested for improving sleep. A small preliminary trial compared the effect of valerian root extract (320 mg at bedtime) and an extract of lemon balm (Melissa officinalis) with that of the sleeping drug triazolam (Halcion®).26 The effectiveness of the herbal combination was similar to that of Halcion, but only the Halcion group felt hung over and had trouble concentrating the next day. A double-blind trial found that a combination of valerian and lemon balm, taken over a two-week period, was effective in improving quality of sleep.27

Another double-blind trial found a combination of 360 mg valerian and 240 mg lemon balm taken before bed improved reported sleep quality in one-third of the participants.28

Combining valerian root with other mildly sedating herbs is common both in Europe and the United States. Chamomile, hops, passion flower, lemon balm, American scullcap, and catnip are commonly recommended by doctors.29 These herbs can also be used alone as mild sedatives for those suffering from insomnia or nervous exhaustion. Chamomile is a particularly good choice for younger children whose insomnia may be related to gastrointestinal upset. Hops and lemon balm are approved by the German government for relieving sleep disturbances.30

Bitter orange has a history of use as a calming agent and to counteract insomnia. There is no clinical trial data to support its efficacy in this regard. The usual amount of tincture used is 2 to 3 ml at bedtime.

Corydalis contains several ingredients, one of which has been shown to influence the nervous system, providing pain relief and promoting relaxation. People with insomnia were able to fall sleep more easily after taking 100–200 mg per day of a corydalis extract (called dl-tetrahydropalmatine, or DHP), according to a preliminary report.31 People taking the extract reported no drug hangover symptoms, such as dizziness or vertigo.

The volatile oil of lavender contains many medicinal components, including perillyl alcohol, linalool, and geraniol. The aroma of the oil is known to be calming32 and thus may be helpful in some cases of insomnia. One trial of elderly people with sleeping troubles found that inhaling lavender oil was as effective as tranquilizers.33 Teas made from lavender flowers or from the oil (1–4 drops) are approved for internal use by the German Commission E for people with insomnia.34 Internal use of essential oils can be dangerous and should be done only with the supervision of a trained herbalist or healthcare professional.

Are there any side effects or interactions with insomnia?

Refer to the individual herb for information about any side effects or interactions.

Holistic approaches that may be helpful for insomnia

Insomnia can be triggered by psychological stress. Dealing with stress, through counseling or other techniques, may be the key to a better night’s rest. Many trials have shown that psychological intervention can be helpful for insomnia.35 A combined program of counseling, sleep restriction methods (i.e., the only time spent in bed is when sleeping), and control of stimuli that might interfere with sleep, significantly increased sleep time in a group of people with insomnia.36

Acupuncture may be helpful for insomnia, possibly by increasing production of calming neurotransmitters such as serotonin and other substances.37 A preliminary trial found one acupuncture treatment daily for seven to ten days resulted in complete recovery of normal sleep in 59% of patients and partial recovery in 21%.38 A controlled trial treated patients with either acupuncture or fake acupuncture (insertion of needles at non-acupuncture points). The patients receiving true acupuncture had significant improvements in a laboratory measure of sleep quality compared to the placebo group.39 The treatment of insomnia with auricular (ear) acupuncture may provide similar benefits to people with insomnia, according to a preliminary trial.40 However, double-blind trials are necessary to conclusively determine the value of acupuncture in treating insomnia.